Background

The assessment of perioperative risk remains a challenge even for expert surgical teams. Evidence based guideline documents have made a definition/criteria of high risk patients. In the functional algorithms, a patient is deemed at prohibitive risk for major resections (lobectomy or pneumonectomy) in case of Vo2peak lower than 35% of predicted or less than 10 ml/kg/min, independent of the spirometric and DlCo values.

Personalised treatment of COPD

COPD (chronic obstructive pulmonary disease) is a disabling disease which causes significant morbidity and mortality. Among COPD, different types of phenotypes exist, which have to be properly diagnosed with consequent personalised treatment, as shown in table 1.

Table 1: Clinical COPD phenotype and treatment

Clinical Phenotype Basic Characteristics and Treatment
Prevailing chronic bronchitis Productive cough more than three months a year for two or more consecutive years.

Chest physiotherapy, PDE4 inhibitor, antibiotic, pharmacological treatment according to guidelines

Prevailing emphysema (hyperinflation) No productive cough; clinical, radiological, functional signs of emphysema.

LVRS (lung volume reduction surgery), bronchoscopic volume reduction, theophylline, pharmacological treatment according to guidelines

Asthma/COPD overlap syndrome (ACOS) Asthma and COPD characteristics. ACOS is considered in the following cases:

  • Very positive bronchodilator test (FEV1 above 15 % and 400 ml), but without normal lung function,
  • Increased NO in the exhaled air > 45–50 ppb and/or eosinophilia in an induced sputum (> 3 %),
  • Previous diagnosis or history of asthma.

The disease is usually accompanied by frequent exacerbations and decreased lung function. Specialist pulmonary treatment is required.

LAMA,LABA+ICS

PDE4 inhibitor in frequent exacerbation

COPD/bronchiectasis overlap syndrome Cough is present on a nearly daily basis, bronchiectasis confirmed by chest X-ray.

Chest physiotherapy with airway clearance techniques, antibiotic according to antibiogram, azithromycin 250 mg 3 times/week **

COPD with frequent exacerbations Two or more exacerbations a year, or hospitalization once a year.

LAMA, LABA+ICS

PDE4 inhibitor, possible azithromycin 250 mg times/week**

COPD with obesity and sleep-related breathing disorder Confirmed diagnosis of COPD, and sleep related breathing disorder confirmed by a polygraph.

CPAP or BiPAP +/- oxygen and pharmacological COPD treatment, weight reduction, treatment of metabolic syndrome if it is present

COPD with cachexia BMI < 21 kg/m2 without any other reason (FFMI < 16/m2 for men or < 15 kg/m2 for women).

Nutritional supplements, rehabilitation (hospital), pharmacological COPD treatment

Legend: BMI: body mass index, FFMI: fat free mass index measured by bioelectrical impedance.
LAMA: long acting anticholinergic, LABA: long acting beta agonist, ICS: inhaled corticosteroides.
** – Only in the centres with expertise.

Personalised asthma treatment

It is important to achieve a good asthma control preoperatively. This is especially important in severe asthma patients. The incidence of severe peri – operative bronchospasm is low, but might be life threatening. In these patients, asthma control might be achieved with the introduction of biologic therapy: omalizumab anti IgE in severe allergic asthma and anti IL-5 in eosinophilic asthma.

Conclusion

Optimal pulmological treatment according to distinct phenotype of obstructive lung diseases represent an important step toward optimisation of clinical condition of the patients.

Literature:

  1. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary diseases 2017 report. Available on: www.goldcopd.com. (availability date: 4. 12 2016).
  2. Brunelli A: Risk assessment for pulmonary resection. Semin Thoracic Surg 2010; 22: 2-13.
  3. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. Revised 2014. Vancouver, GINA, 2016. Available on: www.ginasthma.org (availability date: 17. 5. 2016).
  4. Škrgat S, Triller N, Košnik M et al. Commendations for the management of patients with chronic obstructive pulmonary disease (COPD) at primary and specialist pulmonary levels in Slovenia. Zdr Vestn 2017; 86(1-2):65-75.

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